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Park CH, Lee SH. Effect of lumbar epidural steroid injection on neuropathic pain: a prospective observational study. AIMS Neurosci 2022; 9:24-30. [PMID: 35434275 PMCID: PMC8941192 DOI: 10.3934/neuroscience.2022003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 12/20/2021] [Accepted: 01/05/2022] [Indexed: 11/18/2022] Open
Abstract
Background Low back pain (LBP) is caused by disc herniation, spinal stenosis, facet syndrome or etc. This LBP could be either nociceptive or neuropathic pain (NP). In addition, these neuropathic pain is a major contributor to chronic low back pain. It is already known that lumbar epidural steroid injection (ESI) is effective for low back pain, but no study has assessed both nociceptive and neuropathic pain separately. This study investigated whether neuropathic or nociceptive pain was better improved after an epidural steroid injection. Methods This was a prospective study. Patients were classified according to the pre-procedure painDETECT questionnaire (PD-Q) score. If the PD-Q score was ≤12, it was considered as nociceptive pain, and it the PD-Q was ≥19, it was considered NP. The patients were given a transforaminal (TF) or interlaminar (IL) epidural steroid injection (ESI). The PD-Q was filled out by each patient prior to the ESI (baseline), and again at 4 weeks after the ESI. Outcomes was assessed using a numerical rating scale (NRS) score, short form McGill Pain Questionnaire (MPQ), and revised Oswestry Back Disability Index (ODI) at 1 month later. Results A total of 114 patients were enrolled and of these, 54 patients with a PD-Q score of ≤12 were classified into the nociceptive pain, and 60 patients with a PD-Q score ≥19 were classified into the neuropathic pain group. At 1 month after treatment, both groups had significantly lower than improved their mean NRS score. Not withstanding these improvements and difference between NRS, the differences in MPQ and ODI after treatment between the groups (nociceptive vs. neuropathic) not significant. After the procedure (TF-ESI or IL-ESI), the patients in group 1 (PD-Q score ≤12, n = 54) had no change in their PD-Q score. Among the patients in group 2 (pre-treatment PD-Q score ≥19, n = 41), 13 patients moved to a PD-Q score <12 and 15 patients had a PD-Q score of 13–18. Conclusion For the short-term relief of neuropathic pain, ESI was effective for both nociceptive and neuropathic pain, therefore ESI could be treat the try neuropathic pain component in patients with low back pain.
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Affiliation(s)
- Chan Hong Park
- Department of Anesthesiology and Pain Medicine, Daegu Wooridul Spine Hospital of Daegu, Daegu, South Korea
- * Correspondence: ; Tel: 82532123179; Fax: 82532123049
| | - Sang Ho Lee
- Department of Neurosurgery, Chungdam Wooridul Spine Hospital, Seoul, South Korea
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Sencan S, Celenlioglu AE, Yazici G, Gunduz OH. Transforaminal Epidural Steroid Injection Improves Neuropathic Pain in Lumbar Radiculopathy: A Prospective, Clinical Study. Neurol India 2021; 69:910-915. [PMID: 34507411 DOI: 10.4103/0028-3886.323894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objective This study aims to evaluate the effects of transforaminal epidural steroid injection (TFESI) on neuropathic pain (NP) in patients with chronic unilateral radiculopathy due to lumbar disc herniation (LDH). Patients and Methods Between September 2018 and April 2019, a total of 61 patients who were diagnosed with unilateral/unilevel radiculopathy due to LDH and were scheduled for single-level TFESI were included in this study. The Numeric Rating Scale (NRS), modified Oswestry Disability Index (ODI), Beck Depression Inventory (BDI), and NP-Douleur Neuropathique 4 Questionnaire (DN4) were used before the procedure and at 1 hour, 3 weeks, and 3 months after the procedure. Results There was a significant decrease in the NRS and significant improvement in the ODI, BDI, and DN4 scores in all patients at all postprocedural timepoints (P < 0.05). The number of patients with NP decreased from 35 (60.3%) at baseline to 23 (41.2%) at 3 months (P = 0.001). The NRS scores were similar at 3 weeks and 3 months between the patients with and without NP (P > 0.05). The ODI scores were significantly higher at 3 months in the patients with NP than those without NP (P = 0.013). The BDI scores at baseline, 3 weeks, and 3 months were significantly higher in the patients with NP than those without NP (P < 0.001, P = 0.016, and P = 0.016, respectively). Conclusion Our study results suggest that TFESI is an effective and safe method to decrease not only nociceptive but also NP component in patients with chronic radiculopathy due to LDH. Clinicians should keep in mind that NP is a risk factor that adversely affects the TFESI success and patients should be evaluated before the procedure.
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Affiliation(s)
- Savas Sencan
- Department of Physical Medicine and Rehabilitation, Division of Pain Medicine, Faculty of Medicine, Marmara University, Istanbul, Turkey
| | - Alp Eren Celenlioglu
- Department of Pain Medicine, Health Sciences University, Gülhane Training and Research Hospital, Ankara, Turkey
| | - Gonca Yazici
- Physical Medicine and Rehabilitation Clinic, Malazgirt State Hospital, Mus, Turkey
| | - Osman Hakan Gunduz
- Department of Physical Medicine and Rehabilitation, Division of Pain Medicine, Faculty of Medicine, Marmara University, Istanbul, Turkey
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Sanal-Toprak C, Ozturk EC, Yucel FN, Sencan S, Gunduz OH. Does the presence of neuropathic pain affect the outcomes of the interlaminar epidural steroid injection for cervical disc herniation?: A prospective clinical study. Medicine (Baltimore) 2021; 100:e25012. [PMID: 33655971 PMCID: PMC7939214 DOI: 10.1097/md.0000000000025012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 02/12/2021] [Indexed: 01/04/2023] Open
Abstract
Epidural steroid injections (ESI) are commonly performed for the treatment of chronic cervical disc herniation (CDH). Although they are considered to be effective for both nociceptive and neuropathic types of pain, there is a lack of data regarding the impact of neuropathic pain (NP) and nociceptive pain components on treatment outcomes. The aim of this study is to compare the effectiveness of interlaminar epidural steroid injection (ILESI) between patients with predominantly NP and nociceptive pain due to CDH.Sixty five participants were initially included in the study and assessed by numeric rating scale (NRS), neck pain and disability scale (NPDS), short form-12 (SF-12), and self-reported Leeds assessment of neuropathic symptoms and signs (S-LANSS) pain scale at baseline and 1 month, 3 months, 6 months after ILESI.All patients were evaluated at 1st month and 3rd month follow-up periods while 54 of patients achieved to complete 6th month follow-up. There were significant improvements in all outcome measures for all time periods when compared with the pre-intervention scores. At baseline 24 (36.9%) of patients had predominantly NP in accordance with S-LANSS pain scale. The ratio of NP predominant patients reduced to 7.6% at 1st month, 12.3% at 3rd month, and 12.9% at 6th month with a significant difference for each follow-up period when compared with the baseline. Although all NRS and NPDS scores at baseline were significantly higher in patients with NP, improvement was significant at all follow-up periods in both groups. Minimal clinically important change in NRS was observed in >75% of patients at 1st, 3rd, and 6th month in both groups.The results of this study showed that NP is present in one-third of the patients suffering from neck and radiating arm pain due to CDH and cervical ILESI is an effective treatment approach for both neuropathic and nociceptive components of pain.Clinical Trials Registration Number: NCT04235478.
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Affiliation(s)
| | - Ekim Can Ozturk
- Department of Physical Medicine and Rehabilitation, Pain Medicine Section, School of Medicine, Marmara University, Istanbul, Turkey
| | | | - Savas Sencan
- Department of Physical Medicine and Rehabilitation, Pain Medicine Section, School of Medicine, Marmara University, Istanbul, Turkey
| | - Osman Hakan Gunduz
- Department of Physical Medicine and Rehabilitation, Pain Medicine Section, School of Medicine, Marmara University, Istanbul, Turkey
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Sencan S, Edipoglu IS, Celenlioglu AE, Yolcu G, Gunduz OH. Comparison of treatment outcomes in lumbar central stenosis patients treated with epidural steroid injections: interlaminar versus bilateral transforaminal approach. Korean J Pain 2020; 33:226-233. [PMID: 32606267 PMCID: PMC7336349 DOI: 10.3344/kjp.2020.33.3.226] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 03/08/2020] [Accepted: 03/10/2020] [Indexed: 11/16/2022] Open
Abstract
Background We aimed to compare interlaminar epidural steroid injections (ILESI) and bilateral transforaminal epidural steroid injections (TFESI) on pain intensity, functional status, depression, walking distance, and the neuropathic component in patients with lumbar central spinal stenosis (LCSS). Methods The patients were divided into either the ILESI or the bilateral TFESI groups. Prime outcome measures include the numerical rating scale (NRS), Oswestry disability index (ODI), Beck depression inventory (BDI), and pain-free walking distance. The douleur neuropathique en 4 questions score was used as a secondary outcome measure. Results A total of 72 patients were finally included. NRS, ODI, and BDI scores showed a significant decline in both groups in all follow-ups. Third-month NRS scores were significantly lower in the ILESI group (P = 0.047). The percentages of decrease in the ODI and BDI scores between the baseline and the third week and third month were significantly higher in the ILESI group (P = 0.017, P = 0.001 and P = 0.048, P = 0.030, respectively). Pain-free walking distance percentages from the baseline to the third week and third month were significantly higher in the ILESI group (P = 0.036, P < 0.001). The proportion of patients with neuropathic pain in the bilateral TFESI group significantly decreased in the third week compared to the baseline (P = 0.020). Conclusions Both ILESI and TFESI are reliable treatment options for LCSS. ILESI might be preferred because of easier application and more effectiveness. However, TFESI might be a better option in patients with more prominent neuropathic pain.
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Affiliation(s)
- Savas Sencan
- Division of Pain Medicine, Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Marmara University, Istanbul, Turkey
| | - Ipek Saadet Edipoglu
- Division of Pain Medicine, Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Marmara University, Istanbul, Turkey
| | - Alp Eren Celenlioglu
- Division of Pain Medicine, Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Gunay Yolcu
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Marmara University, Istanbul, Turkey
| | - Osman Hakan Gunduz
- Division of Pain Medicine, Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Marmara University, Istanbul, Turkey
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Sharma AK, Vorobeychik Y, Wasserman R, Jameson J, Moradian M, Duszynski B, Kennedy DJ. The Effectiveness and Risks of Fluoroscopically Guided Lumbar Interlaminar Epidural Steroid Injections: A Systematic Review with Comprehensive Analysis of the Published Data. PAIN MEDICINE 2017; 18:239-251. [PMID: 28204730 DOI: 10.1093/pm/pnw131] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Objective To determine the effectiveness and risks of fluoroscopically guided lumbar interlaminar epidural steroid injections. Design Systematic review of the literature with comprehensive analysis of the published data. Interventions Three reviewers with formal training in evidence-based medicine searched the literature on fluoroscopically guided lumbar interlaminar epidural steroid injections. A larger team consisting of five reviewers independently assessed the methodology of studies found and appraised the quality of the evidence presented. Outcome Measures The primary outcome assessed was pain relief. Other outcomes such as functional improvement, reduction in surgery rate, decreased use of opioids/medications, and complications were noted, if reported. The evidence on each outcome was appraised in accordance with the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system of evaluating evidence. Results The search yielded 71 primary publications addressing fluoroscopically guided lumbar interlaminar epidural steroid injections. There were no explanatory studies and all pragmatic studies identified were of low quality, yielding evidence comparable to observational studies. Conclusions The body of evidence regarding effectiveness of fluoroscopically guided interlaminar epidural steroid injection is of low quality according to GRADE. Studies suggest a lack of effectiveness of fluoroscopically guided lumbar interlaminar epidural steroid injections in treating primarily axial pain regardless of etiology. Most studies on radicular pain due to lumbar disc herniation and stenosis do, however, report statistically significant short-term improvement in pain.
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Affiliation(s)
- Anil K Sharma
- Spine and Pain Centers, Shrewsbury, New Jersey, NJ, USA
| | - Yakov Vorobeychik
- Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Ronald Wasserman
- Back and Pain Center, University of Michigan, Ann Arbor, Michigan, MI, USA
| | | | | | | | - David J Kennedy
- Department of Orthopedics, Stanford University, Redwood City, California, USA
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Singh S, Singh K, Gupta R, Kaur N, Bansal P, Singh S. Correlation of quality of life scores to clinical outcome of lumbar epidural steroids in chronic low back pain. Anesth Essays Res 2016; 10:574-579. [PMID: 27746554 PMCID: PMC5062205 DOI: 10.4103/0259-1162.183563] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
CONTEXT AND AIM The assessment of severity of low back pain includes subjective questionnaires to quantify the impact on routine life. The objective of current study was to correlate various quality of life (QOL) scores to the clinical outcome measured as improvement in Visual Analog Score (VAS) after interventional treatment. SUBJECTS AND METHODS Fifty-one consecutive chronic low backache patients were assessed for pain intensity using VAS, revised Oswestry Disability Index (ODI), Quebec's, Roland-Morris disability questionnaire (RMDQ), and depression score at presentation. All subjects received interventional therapy complemented with physiotherapy; changes in scores were evaluated at 2 weekly intervals till 12 weeks. TYPE OF STUDY Prospective, observational, cohort study. RESULTS All scores depicted highly significant statistical improvement over baseline scores (P < 0.001). The Pearson correlation of VAS with rest of the scores showed that all variables correlate well with VAS at various time periods till 3 months. However, the best outcome predictor for VAS in QOL scores was Oswestry score as well as depression score which had an additive predictive effect. Among the QOL scores best intercorrelation was found with ODI and RMDQ scores at baseline as well as at all treatment follow-ups. INTERPRETATION AND CONCLUSION ODI and depression score closely parallel trends of reduction in VAS indicating that these scores may be the best outcome predictor after interventional treatment of pain. Among QOL scores ODI and RMDQ evaluated in the current study record comparable degree of physical incapacity; the exception is Quebec's score.
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Affiliation(s)
- Saru Singh
- Department of Anaesthesia, BPS Government Medical College, Khanpur Kalan, Sonepat, Haryana, India
| | - Kulvinder Singh
- Department of Radiology, BPS Government Medical College, Khanpur Kalan, Sonepat, Haryana, India
| | - Ruchi Gupta
- Department of Anaesthesia, SGRDIMS&R, Amritsar, Punjab, India
| | - Nayyamat Kaur
- Department of Anaesthesia, Government Medical College and Hospital, Chandigarh, India
| | - Pranav Bansal
- Department of Anaesthesia, BPS Government Medical College, Khanpur Kalan, Sonepat, Haryana, India
| | - Sanjeet Singh
- Department of Community Medicine, BPS Government Medical College, Khanpur Kalan, Sonepat, Haryana, India
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Takahashi N, Shirado O, Kobayashi K, Mashiko R, Konno SI. Classifying patients with lumbar spinal stenosis using painDETECT: a cross-sectional study. BMC FAMILY PRACTICE 2016; 17:90. [PMID: 27443164 PMCID: PMC4957416 DOI: 10.1186/s12875-016-0486-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 07/13/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND The pathological mechanisms of lumbar spinal stenosis are unclear. Family doctors in the primary care setting may perform medical examinations of patients with lumbar spinal stenosis. Our aim was to use the painDETECT questionnaire to quantify the pathological mechanisms of low back pain and/or leg pain caused by lumbar spinal stenosis. METHODS We enrolled 102 patients (37 men, 65 women) who had been newly diagnosed with lumbar spinal stenosis at 2 facilities. The patients' conditions were evaluated using the painDETECT questionnaire, Numerical Rating Scale, Roland-Morris Disability Questionnaire, Japanese Orthopaedic Association Back Pain Evaluation Questionnaire, and 36-Item Short-Form Health Survey. The pathological mechanisms of low back pain and/or leg pain caused by lumbar spinal stenosis were classified based on results of the painDETECT questionnaire as nociceptive pain, neuropathic pain, or unclear type of pain (mixed pain). Statistical analyses were performed using the Kruskal-Wallis test. A value of p < 0.05 was considered to indicate statistical significance. RESULTS The mean age of all patients in this study was 70.3 ± 2 years. The male:female distribution was 37:65 (36.3:63.7 %). In all, 72 (70.6 %) patients had chronic pain (duration of ≥3 months), and 30 (29.4 %) had subacute or acute pain (duration of <3 months). The pain was classified as nociceptive in 59 patients (57.9 %), neuropathic in 18 (17.6 %), and unclear in 25 (24.5 %). The neuropathic pain group had a significantly lower quality of life (p < 0.05) than did the other groups. CONCLUSIONS Patients with neuropathic back and/or leg pain caused by lumbar spinal stenosis may have lower physical and/or psychological quality of life than patients with such pain caused by other mechanisms.
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Affiliation(s)
- Naoto Takahashi
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan. .,Department of Pain Medicine, Fukushima Medical University School of Medicine, Fukushima, Japan. .,Department of Orthopaedic Surgery, Hoshi General Hospital, Koriyama, Japan. .,Department of Orthopaedic and Spinal Surgery, Aizu Medical Center Fukushima Medical University, Aizuwakamatsu, Japan. .,Department of Orthopaedic Surgery, Fukushima Prefectural Minami-Aizu Hospital, Minami Aizu, Japan.
| | - Osamu Shirado
- Department of Orthopaedic and Spinal Surgery, Aizu Medical Center Fukushima Medical University, Aizuwakamatsu, Japan
| | - Kazuki Kobayashi
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan.,Department of Orthopaedic Surgery, Fukushima Prefectural Minami-Aizu Hospital, Minami Aizu, Japan
| | - Ryosuke Mashiko
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan.,Department of Orthopaedic Surgery, Fukushima Prefectural Minami-Aizu Hospital, Minami Aizu, Japan
| | - Shin-Ichi Konno
- Department of Orthopaedic Surgery, Fukushima Medical University School of Medicine, Fukushima, Japan
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Sari S, Aydın ON, Tasdemir B, Galimberti F, Turan A. Effect of statin use on pain relief by transforaminal epidural steroid injection. J Int Med Res 2016; 44:389-94. [PMID: 26912508 PMCID: PMC5580055 DOI: 10.1177/0300060515597934] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 07/06/2015] [Indexed: 11/17/2022] Open
Abstract
Aim To investigate the impact of statin use on response to fluoroscopy-assisted transforaminal anterior epidural steroid injection (TAESI). Methods Patients undergoing TAESI for low back pain were recruited and stratified according to statin use. Pain was evaluated with a visual analogue scale (VAS) before and at 1, 3, and 6 months after TAESI. Health-related quality-of-life was evaluated using the Short Form 36 (SF-36) questionnaire 6 months after TAESI. Results There were no significant differences in VAS scores after TAESI between statin users (n = 40) and statin nonusers (n = 253). The SF-36 subgroup: role limitations due to emotional problems score was significantly lower in statin users than statin nonusers. There were no significant between-group differences in any other SF-36 parameter. Conclusion Statin use had no effect on pain scores after TAESI.
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Affiliation(s)
- Sinem Sari
- Department of Anaesthesia and Reanimation, Adnan Menderes University Medical Faculty, Aydin, Turkey
| | - Osman Nuri Aydın
- Department of Algology, Adnan Menderes University, Aydin, Turkey
| | - Banu Tasdemir
- Department of Anaesthesia and Reanimation, Adnan Menderes University Medical Faculty, Aydin, Turkey
| | | | - Alparslan Turan
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
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Abstract
Chronic pain is a common, complex, and challenging condition, where understanding the biological, social, physical and psychological contexts is vital to successful outcomes in primary care. In managing chronic pain the focus is often on promoting rehabilitation and maximizing quality of life rather than achieving cure. Recent screening tools and brief intervention techniques can be effective in helping clinicians identify, stratify and manage both patients already living with chronic pain and those who are at risk of developing chronic pain from acute pain. Frequent assessment and re-assessment are key to ensuring treatment is appropriate and safe, as well as minimizing and addressing side effects. Primary care management should be holistic and evidence-based (where possible) and incorporates both pharmacological and non-pharmacological approaches, including psychology, self-management, physiotherapy, peripheral nervous system stimulation, complementary therapies and comprehensive pain-management programmes. These may either be based wholly in primary care or supported by appropriate specialist referral.
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Affiliation(s)
- Sarah Mills
- Division of Population Health Sciences, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee, DD2 4BF, Scotland, UK.
| | - Nicola Torrance
- Division of Population Health Sciences, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee, DD2 4BF Scotland UK
| | - Blair H. Smith
- Division of Population Health Sciences, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee, DD2 4BF Scotland UK
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Chou R, Hashimoto R, Friedly J, Fu R, Bougatsos C, Dana T, Sullivan SD, Jarvik J. Epidural Corticosteroid Injections for Radiculopathy and Spinal Stenosis: A Systematic Review and Meta-analysis. Ann Intern Med 2015; 163:373-81. [PMID: 26302454 DOI: 10.7326/m15-0934] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Use of epidural corticosteroid injections is increasing. PURPOSE To review evidence on the benefits and harms of epidural corticosteroid injections in adults with radicular low back pain or spinal stenosis of any duration. DATA SOURCES Ovid MEDLINE (through May 2015), Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, prior systematic reviews, and reference lists. STUDY SELECTION Randomized trials of epidural corticosteroid injections versus placebo interventions, or that compared epidural injection techniques, corticosteroids, or doses. DATA EXTRACTION Dual extraction and quality assessment of individual studies, which were used to determine the overall strength of evidence (SOE). DATA SYNTHESIS 30 placebo-controlled trials evaluated epidural corticosteroid injections for radiculopathy, and 8 trials were done for spinal stenosis. For radiculopathy, epidural corticosteroids were associated with greater immediate-term reduction in pain (weighted mean difference on a scale of 0 to 100, -7.55 [95% CI, -11.4 to -3.74]; SOE, moderate), function (standardized mean difference after exclusion of an outlier trial, -0.33 [CI, -0.56 to -0.09]; SOE, low), and short-term surgery risk (relative risk, 0.62 [CI, 0.41 to 0.92]; SOE, low). Effects were below predefined minimum clinically important difference thresholds, and there were no longer-term benefits. Limited evidence showed no clear effects of technical factors, patient characteristics, or comparator interventions on estimates. There were no clear effects of epidural corticosteroid injections for spinal stenosis (SOE, low to moderate). Serious harms were rare, but harms reporting was suboptimal (SOE, low). LIMITATIONS The review was restricted to English-language studies. Some meta-analyses were based on small numbers of trials (particularly for spinal stenosis), and most trials had methodological shortcomings. CONCLUSION Epidural corticosteroid injections for radiculopathy were associated with immediate reductions in pain and function. However, benefits were small and not sustained, and there was no effect on long-term surgery risk. Limited evidence suggested no effectiveness for spinal stenosis.
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Affiliation(s)
- Roger Chou
- From Pacific Northwest Evidence-based Practice Center, and Oregon Health & Science University, Portland, Oregon; Spectrum Research, Tacoma, Washington; and Comparative Effectiveness, Cost and Outcomes Research Center and University of Washington, Seattle, Washington
| | - Robin Hashimoto
- From Pacific Northwest Evidence-based Practice Center, and Oregon Health & Science University, Portland, Oregon; Spectrum Research, Tacoma, Washington; and Comparative Effectiveness, Cost and Outcomes Research Center and University of Washington, Seattle, Washington
| | - Janna Friedly
- From Pacific Northwest Evidence-based Practice Center, and Oregon Health & Science University, Portland, Oregon; Spectrum Research, Tacoma, Washington; and Comparative Effectiveness, Cost and Outcomes Research Center and University of Washington, Seattle, Washington
| | - Rongwei Fu
- From Pacific Northwest Evidence-based Practice Center, and Oregon Health & Science University, Portland, Oregon; Spectrum Research, Tacoma, Washington; and Comparative Effectiveness, Cost and Outcomes Research Center and University of Washington, Seattle, Washington
| | - Christina Bougatsos
- From Pacific Northwest Evidence-based Practice Center, and Oregon Health & Science University, Portland, Oregon; Spectrum Research, Tacoma, Washington; and Comparative Effectiveness, Cost and Outcomes Research Center and University of Washington, Seattle, Washington
| | - Tracy Dana
- From Pacific Northwest Evidence-based Practice Center, and Oregon Health & Science University, Portland, Oregon; Spectrum Research, Tacoma, Washington; and Comparative Effectiveness, Cost and Outcomes Research Center and University of Washington, Seattle, Washington
| | - Sean D. Sullivan
- From Pacific Northwest Evidence-based Practice Center, and Oregon Health & Science University, Portland, Oregon; Spectrum Research, Tacoma, Washington; and Comparative Effectiveness, Cost and Outcomes Research Center and University of Washington, Seattle, Washington
| | - Jeffrey Jarvik
- From Pacific Northwest Evidence-based Practice Center, and Oregon Health & Science University, Portland, Oregon; Spectrum Research, Tacoma, Washington; and Comparative Effectiveness, Cost and Outcomes Research Center and University of Washington, Seattle, Washington
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Abstract
PURPOSE To determine the prevalence and characteristics of neuropathic pain (NP) in patients with lumbar spinal stenosis (LSS) according to subgroup analysis of symptoms. MATERIALS AND METHODS We prospectively enrolled subjects with LSS (n=86) who were scheduled to undergo spinal surgery. The patients were divided into two groups according to a chief complaint of radicular pain or neurogenic claudication. We measured patient's pain score using the visual analog scale (VAS), Oswestry Disability Index (ODI) and Leads Assessment of Neuropathic Symptoms and Signs (LANSS). According to LANSS value, the prevalence of NP component pain in patients with LSS was assessed. Statistical analysis was performed to find the relationship between LANSS scores and the other scores. RESULTS From our sample of 86 patients, 31 (36.0%) had a NP component, with 24 (63.4%) in the radicular pain group having NP. However, only seven patients (15.6%) in the neurogenic claudication group had NP. The LANSS pain score was not significantly correlated with VAS scores for back pain, but did correlate with VAS scores for leg pain (R=0.73, p<0.001) and with ODI back pain scores (R=0.54, p<0.01). CONCLUSION One-third of the patients with LSS had a NP component. The presence of radicular pain correlated strongly with NP. The severity of leg pain and ODI score were also closely related to a NP component. This data may prove useful to understanding the pain characteristics of LSS and in better designing clinical trials for NP treatment in patients with LSS.
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Affiliation(s)
- Si Young Park
- Department of Orthopedic Surgery, Korea University College of Medicine, Seoul, Korea.
| | - Howard S An
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Seong Hwan Moon
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Hwan Mo Lee
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Woo Suh
- Department of Orthopedic Surgery, Korea University College of Medicine, Seoul, Korea
| | - Ding Chen
- Department of Orthopedic Surgery, The Second Hospital of Xiangya, Central South University, Changsha, Hunan, P.R. China
| | - Jin Ho Jeon
- Department of Orthopedic Surgery, Korea University College of Medicine, Seoul, Korea
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Talukdar R, Reddy DN. Pain in chronic pancreatitis: Managing beyond the pancreatic duct. World J Gastroenterol 2013; 19:6319-6328. [PMID: 24151350 PMCID: PMC3801302 DOI: 10.3748/wjg.v19.i38.6319] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2013] [Revised: 07/31/2013] [Accepted: 08/06/2013] [Indexed: 02/06/2023] Open
Abstract
Chronic pancreatitis (CP) continues to be a clinical challenge. Persistent or recurrent abdominal pain is the most compelling symptom that drives patients to seek medical care. Unfortunately, in spite of using several treatment approaches in the clinical setting, there is no single specific treatment modality that can be earmarked as a cure for this disease. Traditionally, ductal hypertension has been associated with causation of pain in CP; and patients are often subjected to endotherapy and surgery with a goal to decompress the pancreatic duct. Recent studies on humans (clinical and laboratory based) and experimental models have put forward several mechanisms, including neuroimmune alterations, which could be responsible for pain. This might explain the partial or no response to single modality treatment in a significant proportion of patients. The current review discusses the recent concepts of pain generation in CP and evidence based therapeutic approaches (other than ductal decompression) to handle persistent or recurrent pain. We focus primarily on parenchymal and neural components; and discuss the role of antioxidants and the existing controversies, drugs that interfere with neural transmission, pancreatic enzyme supplementation, celiac neurolysis, and pancreatic resection procedures. The review concludes with the treatment approach that we follow at our institute.
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